1093141582 NPI number — MR. SAMUEL JOSEPH HICKS

Table of content: MR. SAMUEL JOSEPH HICKS (NPI 1093141582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093141582 NPI number — MR. SAMUEL JOSEPH HICKS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKS
Provider First Name:
SAMUEL
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093141582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
724 S. CENRTAL, SUITE 101
Provider Second Line Business Mailing Address:
FAMILY SOLUTIONS
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-776-5793
Provider Business Mailing Address Fax Number:
541-776-5798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4434 COREY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRAL POINT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-973-8350
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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